Report On Wood Execution

ARIZONA DEPARTMENT OF CORRECTIONS
Consulting Services for Assessment and

Review of Execution Protocols
December 15, 2014
Assessment and Review of the

Arizona Department of Corrections
Execution Protocols
December 15, 2014
Arizona Department of Corrections Execution Protocols

Assessment and Review
December 15, 2014
TABLE OF CONTENTS
Background ................................................................................................................................................... 1
Project Approach .......................................................................................................................................... 3
National Perspective ................................................................................................................................... 10
Observations of the ADOC Protocol............................................................................................................ 25
Training ....................................................................................................................................................... 36
Summary of State Drug Protocols............................................................................................................... 40
Drug Protocol Considerations and Review ................................................................................................. 44
Findings and Recommendations ................................................................................................................. 48

December 15, 2014
Background
CGL and its partner, Correctional Solutions, Inc. (project team), conducted an independent assessment
and review of the Arizona Department of Corrections (ADOC) execution protocols with respect to the
state-ordered execution of Joseph R. Wood III. This review was completed at the request of the ADOC
and consistent with the scope and requirements outlined in Solicitation No. ADOC15-000043901,
entitled Consulting Services for the Assessment and Review of Execution Protocols.
Joseph R. Wood III was executed on July 23, 2014, at the Arizona State Prison Complex (ASPC)-Florence
Central Unit consistent with the amended warrant of execution issued by the Arizona Supreme Court on
May 30, 2014. Based on investigative reports provided by the ADOC, review of witness statements, and
review of other official documents, the execution drug protocol commenced at 1:52 p.m. on July 23,
2014. At 1:57 p.m., the IV team leader verified that Mr. Wood was sedated. The drug protocol was
repeated 14 additional times until death was pronounced by the IV team leader at 3:49 p.m.
The elapsed time from commencing the drug protocol to pronouncement of death is unprecedented in
comparison to prior executions within Arizona and other death penalty jurisdictions in the United States.
As a result, the ADOC retained CGL to conduct a comprehensive review of the existing ADOC protocols,
the application of these protocols in the case of Joseph R. Wood III, and an assessment as to whether
the existing protocols are consistent with national best practices.
The specific scope of work developed for this project is intended to achieve the project objectives as
stated in the following key elements:
Complete a full assessment of the ADOC execution protocols and procedures. Included in this
review was an on-site walkthrough of the protocol as it was utilized in the case of Joseph R.
Wood III, including the completion of interviews with all staff present and participating in the
execution, a review of execution logs to determine any deviations from required protocol, and a
review of other available documentation related to this execution.
Assess the application and compliance with these protocols and procedures as they apply to the
case of Joseph R. Wood III.
Complete a review and comparison of the ADOC protocols and procedures with those utilized in
other state systems. State protocols presently in place for 10 different states were obtained,
reviewed, and a comparison completed to those in place in the ADOC. Information on the drug
protocol only was obtained from 2 additional states. Staff from 12 states were contacted to
obtain additional information/clarification on the development and implementation of their
respective protocols. The focus of these interviews was on those systems that have divergent
protocols and procedures to those in place in Arizona.
Obtain input from experienced medical professionals on the pharmacological effects of the
combination of midazolam and hydromorphone in quantities of 50 mg. or more.
Conduct a review of the Ohio execution protocol litigation and other available opinions and/or
documents related to the pharmacological application of drugs in an execution protocol.
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December 15 2014
The overall purpose of the state reviews was to determine if those alternative protocols are appropriate
for the Arizona system. Based on the review of ADOC protocols, the comparison of ADOC protocols to
other state correctional systems, information obtained from interviews with representatives of other
states, and the project teams experience, recommendations for possible modification and
improvement to the ADOC protocols will be developed.
CONFIDENTIALITY
The ADOC and the project team formally agreed to make all reasonable efforts to maintain the
confidentiality of information provided by the ADOC during the course of this assessment. The project
team also agreed not to make any duplication or other copies of confidential material obtained during
the course of this assessment or provide confidential material or documents to persons or entities not a
party to this contract (this includes any future solicitations, responses to potential customers, or any
future engagements) without written authorization from the ADOC.
In addition, the project team agreed to be bound by confidentiality agreements in place between the
ADOC and individuals who participate in the execution protocols. These agreements ensure that those
participating in the execution protocol will remain anonymous and will be identified only by their role
and function. As a result, most interviews with staff participants in the execution protocol were done by
phone.
Issues of confidentiality were also encountered in discussions with other state correctional systems in
the review of their existing execution protocols. In many instances the execution protocols, including
the drug protocols, are public documents and are accessible for review; however, in some states the
execution protocols are restricted documents and are not available for public access. The project team
was permitted access to these protocols while guaranteeing that confidentiality be maintained on the
source. In other cases, the jurisdiction did not permit access to the protocol but did have staff brief the
project team on the contents of the protocol and, specifically, the drug regimen used in the execution
procedure. In the course of this review, the project team agreed not to disclose the specific states in
which the protocols reviewed were restricted. In these cases, the states are identified and referenced
by an alphabetic code (State A, State B, State C, etc.).

December 15, 2014
PROJECT APPROACH
PROJECT TEAM
The project team has experience in developing execution protocols, conducting evaluations of their
effectiveness and efficiency, and in directly supervising the execution process in the states in which they
were correctional administrators.
Kenneth McGinnis served as the project director for this review. He has more than 42 years of
professional experience in the management of correctional institutions, programs, and organizations
and has spent the last 14 years providing consultation to correctional agencies and organizations across
the United States. His governmental responsibilities have ranged from the management and
administration of all facets of the Illinois and Michigan correctional systems to serving as warden and
directing the operations of maximum-, medium-, and minimum-security adult institutions. He served as
the chief administrative officer of two of the nations largest and most complex correctional systems:
the Illinois Department of Corrections and the Michigan Department of Corrections.
As Director of the Illinois Department of Corrections, Mr. McGinnis was charged with the responsibility
of creating the execution protocol for the State of Illinois when the death penalty was reinstated. He
directed the development of the protocol that was used in Illinois until the suspension of the death
penalty. In the course of this process he researched and evaluated protocols in place in several systems
and developed a protocol based on national best practices and consistent with Illinois law.
Since 2000, Mr. McGinnis has been assisting other systems in improving their operational protocols and
in conducting performance assessments on a wide range of operational issues. These have included
post-incident reviews of significant critical events that have occurred in correctional systems in several
jurisdictions.
Ron Angelone has served as the head of two major state correctional systems. He was appointed by the
Governor of the Commonwealth of Virginia as Director of the Virginia Department of Corrections on
May 1, 1994, and served until September 2002. During his tenure, he was responsible for the
supervision and administration of all institutions in the department and for probation and parole
services throughout the state. He was also directly responsible for the formulation of administrative
policies and programs for the department and interpretation of the policies, outlining plans and
procedures to employees and appointing officers and employees best qualified to carry on the
departments mission.
During his tenure in Virginia, Mr. Angelone oversaw the execution of more than 85 individuals. He is
familiar with the national protocols, procedures, and policies as related to the conducting of an
execution consistent with national standards and established legal requirements.
Prior to serving in Virginia, Mr. Angelone had been appointed by the Governor of the State of Nevada in
June 1989 to serve as the Director of the Nevada Department of Corrections. In this position he was
responsible for the overall supervision, direction, and administration of all correctional institutions
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December 15, 2014
within the state, including the formulation, interpretation, and implementation of policies, plans, and
procedures to meet the agencys mission.
Mr. Angelone is an active member of the American Correctional Association and has served as chairman
of the standards committee from 2000-2002 and as chairman of the adult corrections committee from
1997-1999. In addition, he is active in the Association of State Correctional Administrators and served
that organization as chairman of the past president committee (2002-present), president (2000-2002),
vice-president (1998-2000), and treasurer (1996-1998). He was also a recipient of the Michael Franke
Award in 2000: the highest honor the association bestows on its members.
Dave Runnels has more than 30 years of experience working in the criminal justice system, culminating
in his appointment as Undersecretary for the California Department of Corrections and Rehabilitation
(CDCR) and Chief Deputy Receiver/Chief of Staff for the Office of the Federal Court Receiver.
Mr. Runnels has been appointed to four governors office positions under the Davis and Schwarzenegger
administrations and confirmed by the full California State Senate. Mr. Runnels has routinely identified
and provided recommendations to the governor, legislature, and department of finance to improve
policies in California. He has also served as Policy Advisor to the Secretary for the CDCR, as
undersecretary of operations, and warden at High Desert State Prison.
Mr. Runnels was the deputy director in the CDCR when executions were reinstated after many years in
delays. He was assigned to lead an effort to assess the protocol in place in other systems. As a result, a
revised protocol was developed. Mr. Runnels participated in executions in CDCR in the operations center
and was the ranking person at the Michael Angelo Morales execution, which was stopped by the court.
This case resulted in the Morales v. Tilton litigation, which stayed executions in the State of California
and challenged CDCRs administration of its lethal injection protocol. Morales challenged the
constitutionality of his execution, contending that San Quentin State Prison operational procedure and
the manner in which the department implements it would subject him to an unnecessary risk of
excessive pain, thus violating the Eighth Amendment's command that cruel and unusual punishments
not be inflicted. Mr. Runnels led an extensive internal review of the CDCR protocol, which resulted in
the implementation of revised policy and procedures and the issuance of an internal report on the
protocols in place prior to the Morales litigation.
SUMMARY OF KEY TASKS

As noted in the background section to this report, several key tasks were completed during the course of
this review. This includes interviews with a wide range of staff and external individuals who were
directly or indirectly involved in the execution of Joseph R. Wood III. In order to maintain the required
anonymity of those directly involved in the implementation of the protocol, many of those interviewed
are not identified by name. Those who are identified by title or role only were interviewed by phone so
as to ensure their confidentiality.
In addition, numerous documents were reviewed during the course of the assessment. The following is a
list of the key interviews and the documents reviewed.
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INTERVIEWS
The following individuals were interviewed by the project team over the course of this assessment. As
noted previously, the identity of several individuals will remain anonymous consistent with the
agreements of the ADOC and these individuals. In these cases their role/function is identified.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
Charles Ryan, Director, Arizona Department of Corrections

Jeff Hood, Deputy Director
Greg Lauchner, Inspector General
Dawn Northup, General Counsel
Carson McWilliams, Division Director, Offender Operations; ADOC Training Coordinator
Lance Hetmer, former Warden of ASPC-Florence
Greg Fizer, Warden of ASPC-Florence
Special operations team leader
IV team leader/attending physician
Housing Unit 9 section leader
Housing Unit 9 recorder
Maintenance response team leader
Designated execution commander
Execution restraint team leader
Brandon Rodarte, Inspector General/CIU Supervisor
Special operations team member
Doctor Gregory Hess, Medical Examiner of Pima County, Arizona
Correctional medical physician, correctional health care consultant expert, and emergency room
physician (not identified by name)
Steve Gray, Chief Counsel, Ohio Department of Corrections and Rehabilitation
Kim Thomas, Director, Alabama Department of Corrections
Anne Adams Hill, Chief Legal Counsel, Alabama Department of Corrections
Dave Robinson, Chief of Correctional Operations, Virginia Department of Corrections
Bryon Collier, Deputy Executive Director, Texas Department of Criminal Justice
Jon Pence, Deputy Warden of Operations, Chillicothe Correctional Institution, Ohio Department
of Corrections and Rehabilitation
LaDonna Thompson, Director, Kentucky Department of Corrections
Brian Owen, Director, Georgia Department of Corrections
Robert Patton, Director, Oklahoma Department of Corrections
Bruce Lemon, Director, Indiana Department of Corrections
William Wilson, Executive Director, Adult Facilities, Indiana Department of Corrections
DOCUMENTS REVIEWED
The following documents were reviewed and examined by the project team in the course of conducting
this assessment. These documents were also utilized in the course of conducting the interviews with
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the above-noted individuals. It is noted that several of the state execution protocols were considered
restricted and not public documents. In these cases, the state is not specifically identified but is
referenced by an alphabetical code. In some cases, the state protocols were not made available to the
project team in hard or electronic copy, but team members were permitted to review the actual
protocol or were briefed on the specifics of the protocol by agency staff. In other cases, the specifics of
the protocols became known through court filings and through news articles.
1. Arizona Department of Corrections, Department Order 710, Execution Procedures, Effective
September 21, 2012, with replacement page revision dated March 26, 2014.
January 25, 2012, with replacement page revision dated June 5, 2012.
3. Arizona Department of Corrections, Department Order 710, Execution Procedures, Effective May
12, 2011, with replacement page revisions dated September 12, 2011, and June 10, 2011.
September 15, 2009, with replacement page revisions dated September 29, 2010 and
September 24, 2010.
5. Investigative Report, Execution of James Rudolph Wood III, Office of the Inspector General,
Arizona Department of Corrections.
6. Amended Warrant of Execution, Supreme Court of Arizona, filed May 30, 2014.
7. Photo Log, Execution of Joseph Rudolph Wood III, Office of the Inspector General, Arizona
Department of Corrections.
8. Pinal County Medical Examiners Office, Preliminary Death Report, dated July 23, 2014, Joseph
Rudolph Wood III.
9. Execution Procedures Checklist, Execution of Joseph Wood III.
10. Correctional Service Log, Housing Unit 9, Special Operations, Execution of Joseph R. Wood, Time
Period Covered: 0800 on 7/23/14 through 1718 on 7/23/14.
11. Correctional Service Log, Lethal Injection Room Log, Restraint Team, Execution of Joseph R.
Wood III, Time Period Covered: 1323 on 7/23/14 through 1349 on 7/23/14.
12. Correctional Service Log, Housing Unit 9 Section Leader, Execution of Joseph R Wood III, Time
Period Covered: 0800 on 7/23/14 through 1650 on 7/23/14.
13. Command Center Execution Log, Joseph Rudolph Wood #086279, July 23, 2014, Time Period
Covered: 0600 on 7/23/2014 through 1635 on 7/23/2014.
14. ASPC-Tucson Criminal Investigation Unit, Supplemental Investigative Report, Execution of Joseph
Rudolph Wood III, Office of the Inspector General, Arizona Department of Corrections.
15. Arizona Department of Corrections, Evidence and Chain of Custody Log, Execution of Joseph
Wood.
16. Arizona Department of Public Safety, Agency Request for Scientific Examination, Submission of
Execution Drugs for Scientific Analysis, Joseph Wood III.
17. Arizona Department of Corrections, Contraband/Evidence Control, Control Number 14-196,
Execution of Joseph Wood.
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December 15, 2014
18. Pima County Forensic Science Center, personal effects receipt, Case Number 14-01808, Joseph R
Wood III.
19. Arizona Department of Public Safety, Scientific Examination Report, dated August 8, 2014,
Execution Drugs for Scientific Analysis, Joseph Wood III.
20. State of Arizona Department of Health Services, Certificate of Death, Joseph R. Wood III, dated
August 22, 2014.
21. Autopsy Report, Pinal County, Arizona, Joseph R. Wood III.
22. Toxicology Report, Joseph R. Wood III, August 21, 2014.
23. Execution procedures checklists, Joseph Wood III, checklist began on June 18, 2014.
24. Execution Training Notes and Records, July 21, 2014.
25. Execution Training Notes and Records, July 22, 2014.
26. Execution Training Notes, October 7, 2013.
27. Execution Training Notes and Records, October 21, 2014.
28. Execution Training Notes and Records, October 22, 2014.
29. Medication administration records for Joseph R. Wood III for July 2014 at ASPC EymanBrowning.
30. Order, United States District Court, Southern District of Ohio, Eastern Division, Case NO. 2:11-ev1016, Ohio Execution Protocol Litigation, order issued January 13, 2014.
31. Opinion and Order, United District Court, Southern District of Ohio, Eastern Division, Case NO.
2:11-ev-1016, Ohio Execution Protocol Litigation, Order Issued January 13, 2014.
32. Letter from the Office of the Federal Public Defender to Charles Ryan, dated January 27, 2012.
33. List of attending witnesses, Execution of Joseph Rudolph Wood III.
34. Statement of Daniel Hughes, Chief of Police, Florence, Arizona, dated August 4, 2014.
35. Memorandum dated August 20, 2014, Phillip Schonig, Supervisor AIU, Interview with Deacon Ed
Scheffer.
36. Memorandum and audio recording dated August 20, 2014, Phillip Schonig, Supervisor AIU,
Inspector General, Interview with Jeanne Brown.
Interview with Troy Hayden, KSAX Fox 10.
38. Memorandum and audio recording dated August 15, 2014, 2014, Jason Fisk, Investigator,
Interview with Terry Adriance, Arizona Board of Executive Clemency.
39. Memorandum and audio recording dated August 20, 2014, Jason Fisk, Investigator, Interview
with Richard Brown.
Interview with Jan Upchurch, Victim Services Administrator.
with Jessica Raak, ADOC Mental Health Monitor.
Interview with Doug Nick, Communications Director.
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December 15, 2014
with Jeanette Guerrero, ADC Office of Victim Services.
Interview with Deputy Warden Morris.
with Stephanie Grisham, Arizona Attorney General Press Secretary.
with Candice Young, Corrections Officer II, ASPC-Lewis.
with Michael Clark.
Interview with Warden James ONeal, ASPC-Phoenix.
49. Disk of Housing Unit 9 photos documenting locations visited and observed by the project team.
50. Statement of Julie Singleton Hall, Attorney at Law, September 8, 2014, delivered by email to
Greg Lauchner, Inspector General.
51. Volume 1, Transcript of Motions Hearing, United States District Court, Southern District of Ohio,
Eastern Division, Case NO. 2:11-ev-1016, Ohio Execution Protocol Litigation.
52. Volume 2, Transcript of Motions Hearing, United States District Court, Southern District of Ohio,
Eastern Division, Case NO. 2:11-ev-1016, Ohio Execution Protocol Litigation.
53. Executive Summary, Ohio Department of Rehabilitation and Correction, Execution of Dennis
McGuire, January 16, 2014.
54. Declaration of IV Team Leader, Execution of Joseph Wood III, statement dated July 25, 2014.
55. Summary spreadsheet of Arizona DOC executions since April 25, 2012.
56. Summary spreadsheet of Arizona DOC executions since 10/26/2010 with drug protocol for each
execution noted.
57. Summary of Special Operations Log, Section Leader Log, and Lethal Injection Room Log.
58. Policy Summary Sheet, DO 710.
59. Execution Protocol, Kentucky Department of Corrections, Lethal Injection Protocols.
60. Oklahoma Execution Protocol, OP-040301, Effective 9/30/2014.
61. Texas Department of Criminal Justice Execution Protocol.
62. Ohio Department of Rehabilitation and Correction, Execution Protocol, 01-COM-11, Effective
October 10, 2013.
63. Execution Protocol, Preparation and Administration of Chemicals for Lethal Injection, Missouri
Department of Corrections.
64. Execution protocols for six unidentified state departments of corrections: specific state identity
withheld at the request of the state administrators/legal counsel.
HOUSING UNIT 9 REVIEW

On September 24, 2014, the project team completed an on-site visit to ASPC-Florence. Within ASPCFlorence is Housing Unit 9, which is the location of all executions in the State of Arizona. Inmates
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December 15, 2014
scheduled for execution are housed at ASPC-Eyman until the evening before the scheduled execution,
when they are relocated to Housing Unit 9. The inmate is housed in a small detention area immediately
adjacent to the execution chamber. The unit also has a witness observation area, a command center for
the execution, and the lethal injection room. All direct activities in preparation and completion of the
execution are conducted in Housing Unit 9.
The project team completed a walkthrough of Housing Unit 9 and received a detailed explanation of the
functions and processes completed in the area as it pertains to the implementation of the execution
protocol. In addition, the role and function of each staff member present during the protocol was
explained in detail. The project team was accompanied by Jeff Hood, Deputy Director, Greg Lauchner,
Inspector General, and Brandon Rodarte, Inspector General Supervisor.

December 15, 2014
NATIONAL PERSPECTIVE
The project team completed a comparative review of lethal injection protocols for the ADOC and 10
state protocols that were obtained through discussion with the administrative officials of the various
state systems. As noted previously in this report, issues of confidentiality arose in discussions with
several of the states. As a result, the project team committed to maintaining the confidentiality of
several of the states by withholding their specific identities. The project team was able to review the
protocols and interview staff where necessary to clarify any provisions contained in the protocols. The
state systems in which the protocols were provided and are considered public documents included
Arizona, Ohio, Kentucky, Oklahoma, Texas, and Missouri. Four other states provided information on
their protocols or permitted the project staff to review the documents, but did not provide a copy of the
protocol. Two other states provided detailed information only on the chemicals used in the execution
protocol. The information provided was supplemented by available court documents, news reports, and
statements for those involved in the process in each state.
The review of state execution protocols focused on several key areas that the project team considers
critical to the process. These included:
Selection process of execution team members

Execution team member training
Execution team record keeping
Medical file review
Drug protocols
The details of the comparative review are outlined in the following summaries.
COMPOSITION OF EXECUTION TEAM AND SELECTION PROCESS

Arizona
The ADOC execution protocols require 10 teams and approximately 46 staff to assist with all operational
areas within the prison during executions. Execution team members are selected by the division
director(s) based on established screening criteria and include documented approval of the director.
Medical team member qualifications are verified and documented. The 10 teams identified are the
command team, housing unit team, restraint team, special operations team, IV team, maintenance
response team, critical incident response team, traffic control team, escort team, and victim services
team. Each team has specific written duties and responsibilities.
State B
State Bs execution policy calls for no less than 12 execution team members to carry out the courtordered executions within the system. The execution team members are designated and selected by
the warden. State Bs policy does not provide established screening criteria to be utilized in team
member selection. The warden may also designate a physician as an auxiliary team member to provide
consultation or advice. Medical team member qualifications are verified and documented.
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State C
State Cs execution procedures call for no less than 20 members recruited by the warden with the
assistance of the director. State Cs policy identifies established screening criteria for consideration in
team member selection.
State D
State Ds execution team members and team member selection procedures are not referenced in the
lethal injection protocols obtained.
State E
State Es execution procedure calls for the execution team to be selected by the team warden
designated by the secretary. The team warden is authorized to select a sufficient number of team
members to cover 13 identified areas and has the authority to assign staff as necessary for any other
necessary tasks to carry out the execution. State Es policy does not provide established screening
criteria for consideration in team member selection.
State F
State Fs execution procedures call for 10 teams and approximately 46 team members to assist with all
operational areas within the prison during executions. Team members are selected through the
wardens recommendations, evaluated by the division managers, and provided to the director for
documented approval. Team member selections are based on established screening criteria. The 10
teams identified are the command team, housing unit team, restraint team, special operations team, IV
team, maintenance response team, critical incident management team, traffic control team, witness
escort teams, and victim services team.
State G
State Gs execution team members and team member selection procedures are not referenced in the
State H
State Hs execution procedures require approximately 18 team members to assist with the scheduled
execution. Team members are selected by the warden. State Hs policy does not provide established
screening criteria for consideration in team member selection.
State I
State Is execution procedures require a combination of department employees and contracted medical
personnel, including a physician, nurse, and pharmacist. The execution team is selected by the director.
State Is policy does not provide established screening criteria for consideration in team member
selection.
State J
State Js execution team members and team member selection procedures are not referenced in the
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EXECUTION TEAM MEMBER TRAINING

Arizona
Per the protocol, the director schedules 10 training scenarios within 12 months preceding any scheduled
execution. The training protocol establishes a roll over schedule that ensures that the training
requirement is met for all scheduled executions. The director schedules a minimum of two training
sessions with multiple scenarios two days prior to the scheduled execution. All training sessions are
documented. Beginning 35 days prior to the scheduled execution date, execution team members who
are participating in the execution receive training, written instruction, and practiceall of which is
documented.
State B
Per the protocol, beginning 30 days prior to the scheduled execution date, the execution team begins
conducting training sessions no less than once per week until the scheduled execution date. The team
leader provides each execution team member a copy of the current execution policy, and all team
members sign for its receipt.
State C
The team administrator conducts training simulations for execution team members on a monthly basis.
Upon receipt of a death warrant, training is scheduled in the 30 days immediately preceding the
scheduled execution. Team members must have participated in six training sessions prior to being
assigned duties during an execution. Execution team members also participate in three daily training
sessions immediately preceding the scheduled execution. The team leader maintains a lethal injection
process training file documenting all process training sessions.
State D
There is no specific execution team member training referenced in the lethal injection protocols
obtained from this jurisdiction.
State E
The state protocol requires that the team warden conduct simulations of the execution process, at a
minimum, on a quarterly basis and a simulation the week prior to any scheduled execution. All persons
involved with the execution should participate in the simulations. A written record of any training
activities is required.
State F
The division manager schedules 10 training scenarios within 12 months preceding a scheduled execution
for periodic on-site practice by the housing unit team. Beginning 35 days prior to the execution date,
the housing unit team initiates training sessions no less than once per week until the scheduled date of
the execution. The housing unit team conducts a minimum of two training sessions with multiple
scenarios two days prior to the scheduled execution. The command team leader conducts training for
the witness escort team, maintenance response team, critical incident management team, traffic control
team, and victim services team seven days prior to the execution date. The IV team participates in at
least one training session with multiple scenarios within one day prior to the scheduled execution date.
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State G
The procedures reference that the drug team is to have one medically trained individual who has
followed the drug team through at least two executions, received step-by-step instructions from existing
team members, and participated in at least two executions under the direct supervision of existing team
members. There is no additional execution team member training referenced in the lethal injection
protocols obtained.
State H
obtained.
State I
obtained.
State J
obtained.
EXECUTION TEAM RECORD KEEPING

Arizona
The ADOCs execution protocols require record keeping in the following areas:
Training sessions
Team member approval
Execution team recorder
Notice of execution involvement (signed by all execution team members)
Letter of invitation to witness an execution
Official witness agreement (signed by all witnesses, approved by director)
Official witness/pool reporter agreement (signed by all media, approved by director)
Wardens 35-day confirmation
Inmate continuous observation record/log
Return of death warrant notification (signed by warden/directors notification to supreme and
superior courts)
Certificate of death (medical examiner)
Debrief
State B
The execution policy for this jurisdiction requires execution events be documented in an execution
timeline and requires that all actions by department personnel in carrying out the sentence be fully
documented. State Bs policy requires documentation in the following areas:
Medical assessment of prisoner

Mental health assessment of prisoner
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Execution team training

Execution information release
Continuous prisoner monitoring
Mental health progress reports
24-hour medical evaluation (vein assessment and medical file review)
Inmate property record disposition and release
Morning of execution vein assessment
Order for execution medications
Drug preparation
Confirming and recording establishment of IV sites (# of attempts)
Start and finish times of each injection
Changes to alternative IV sites
Warden decisions during execution
Death warrant (signed by warden)
Disposal of prepared execution drugs
Return of unprepared execution drugs
Recording of used execution drugs
After action review
Quality assurance review
State C
The execution procedures include a record keeping sub-team and require record keeping in the
following areas:
Security
Intravenous
Infusion
Team administrator
Team leader
Training
Facility inspection
Lethal injection process
Inmate activities
Notifications to inmate execution date and choice of execution method
Death warrant
Media notification
Medical review documentation
Inmate visiting records
Inmates execution information
Execution logs
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Equipment accountability report

Execution records
Post execution records
Legal documents
Execution report
Return of death warrant/certificate of death
Wardens after action critique
State D
The lethal injection protocols of this jurisdiction require record keeping in the following areas:
Execution drug storage

Disposal of unused execution drugs
Return of unprepared execution drugs
State E
The jurisdictions execution procedures require the use of appropriate checklists to document the lethal
injection procedures upon completion of each step in the process, include independent law
enforcement agents who keep execution room and execution chamber logs during the execution
process, and reference record keeping in the following areas:
Training activities
Executioners room log (documented at two-minute intervals)
Execution chamber log (documented at two-minute intervals)
Medical examination
Time of death
Death certificate
Warrant of execution/wardens signed statement
State F
This jurisdictions execution procedures require record keeping in the following areas:
Team member approval

Execution command team recorder
Special operations team recorder
Training sessions
Witnesses
Notification letter to dignitaries/law enforcement
Notification letter to offender witnesses
Wardens 35-day confirmation
Medical assessment
Mental health assessment
Offender continuous observation log
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Special operations team recorder execution timeline

Signing and filing of death warrant
Certificate of death
After action review
Quality assurance review
State G
This jurisdictions lethal injection protocols require record keeping in the following areas:
Execution summary packet

Execution watch log
Execution transportation log
State H
This jurisdictions lethal injection procedures require record keeping in the following areas:
Controlled chemical inventory

Chemicals administered during execution
Chemicals destroyed after execution
Chemicals returned after execution/stay
State I
This jurisdictions lethal injection protocols require record keeping in the following areas:
Disposal of unused chemicals

Sequence of chemical form
Chemical log quantities used and discarded
State J
There is no specific record keeping referenced in the lethal injection protocols obtained from this
jurisdiction.
MEDICAL FILE REVIEW

Arizona
The ADOCs protocols require that a contracted health provider conduct a medical records file review 35
days prior to the scheduled execution to identify any prescribed medication(s) and dosages the inmate is
currently, or was recently, taking and modify as necessary, ensuring the offender medications are unit
dosed and any keep-on-person medications are removed.
State B
This jurisdictions policy requires a medical chart review 21 days prior to the scheduled execution to
establish any unique factors which may impact the manner in which the execution team carries out the
execution, as well as a medical condition assessment and mental health evaluation to identify any
necessary accommodations or contingencies that may arise from the prisoners medical condition or
history.
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December 15, 2014
State C
The execution procedures require a vein assessment to determine the size, location, and resilience of
the inmates veins and a medical review at 20 days and again at 7 days prior to the scheduled execution
to establish the inmates psychiatric condition.
State D
The jurisdictions protocols do not require a review of the inmates medical file prior to the execution.
State Ds protocols require an examination of the condemned persons veins within 24 hours prior to the
execution to determine possible locations for the IV sites and within 5 hours of the execution require an
examination to determine the appropriate size needle to be used.
State E
The jurisdictions procedures require one or more designated execution team members review the
inmates medical file in order to determine whether there are any medical issues that could potentially
interfere with the proper administration of the lethal injection process.
State F
This jurisdictions procedures require that health services staff conduct a medical records file review 35
days prior to the scheduled execution to identify any prescribed medication(s) and dosages the inmate is
currently, or was recently, taking. Health services staff will modify prescribed medication as necessary
and ensure the offender medications are unit dosed and any keep-on-person medications are removed.
State G
Procedures require that any keep-on-person medication be removed from the inmate upon notification
of the execution date, and that the inmates medical file be transported with the condemned person to
the execution unit.
State H
The protocols do not require a review of the inmates medical file prior to the execution.
State I
There is no review of the inmates medical file prior to the execution referenced in the lethal injection
protocols obtained.
State J
There is no review of the inmates medical file prior to the execution referenced in the lethal injection
protocol obtained.
EXECUTION TEAM PREPARATION AND ADMINISTRATION OF DRUG PROTOCOL

Arizona
The ADOC director has the discretion, 20 calendar days prior to the scheduled execution, to identify
whether a one- or two-drug protocol will be utilized. The drug protocol identified is reported to the
inmate at that time.
Preparation: At the appropriate time, the special operations team leader takes custody of the
chemical(s) from a secure location and, with assigned team members, begins the chemical and syringe
17

December 15, 2014
preparation in the chemical room under the direct supervision of the IV team leader. The team
prepares one complete set of chemicals, labeling the assigned sterile syringes in a distinctive manner
and identifying the specific chemical(s) contained in each syringe by assigned number, chemical name,
chemical amount, and designated color in conformance with chemical chart protocols. The flow of each
gauge is checked by the IV team leader; the syringes are affixed to the manifold in the proper order and
verified by the special operations team leader.
Administration: The inmate is escorted into the execution room. Closed-circuit monitors allow
witnesses to observe the establishment of the IV sites. A microphone is attached to the inmate to allow
the team to directly communicate with the inmate and hear any utterances or noises made by the
inmate throughout the procedure. The electrocardiograph leads are affixed to the inmates chest. The
IV team leader ensures the proper placement and a flow of heparin/saline is started to keep the lines
open. The warden physically remains in the room with the inmate throughout the administration of the
lethal chemical(s) in a position sufficient to clearly observe the inmate and the primary and backup IV
sites for any potential problems. Upon direction from the special operations team leader, the assigned
team member visually and orally confirms the chemical name on the syringe and then administers the
full dose of the lethal chemical(s) immediately followed by the heparin/saline flush. The inmates
consciousness level is reviewed after three minutes. If deemed appropriate, the director may instruct
the special operations team to administer an additional dose of the lethal chemical(s) followed by the
heparin/saline flush. The special operations team recorder documents on the correctional services log
the start and end times of the administration of the lethal chemical(s). The IV team members, special
operations team members, and the warden continually monitor the inmate using all available means to
ensure the inmate remains unconscious and that there are no complications. Upon completion of the
process, death is pronounced.
State B
State Bs warden determines, 14 days prior to the scheduled execution, whether a sufficient amount of
the one-drug protocol is available for use, or whether the two-drug protocol will be utilized. The warden
advises the inmate of the drug protocol to be used.
Preparation: On the morning of the execution, a drug administrator, in the presence of a second drug
administrator, takes custody of the execution drug(s) from the institution pharmacy storage area,
delivers the drug(s) to the execution location, and prepares the drugs for injection. The chemicals are
divided into syringes and labeled according to the drug protocol identified for use. Additional syringes
and chemicals are labeled and available in the event the primary dosages prove to be insufficient. The
second drug administrator monitors the preparation and independently verifies the preparation and
dosage of the drug(s).
Administration: The inmate is escorted into the execution room. Closed-circuit monitors allow
witnesses to observe the establishment of the IV site(s). The medical team member tests the viability of
the IV site with a low-pressure saline drip. A heparin lock may be attached to the IV needle as an
alternative to the saline drip. Upon direction from the warden, a drug administrator intravenously
18

December 15, 2014
administers the prepared syringes, followed by a low-pressure saline drip to flush the lines upon
completion of the drug administration. A second drug administrator observes the administration of the
execution drugs and announces the start and finish times of each injection for documentation in the
execution timeline. Following administration of the IV drug(s), the inmates consciousness level is
reviewed. If a sufficient time for death to occur has passed, but the inmate has not died, the medical
team consults with the warden and director. The warden, after consultation with the director,
determines whether to proceed with additional syringes of execution drug(s) and may order the medical
team to prepare such additional syringes, as necessary, and intravenously administer them in
accordance with policy. Upon completion of the process, death is pronounced.
Additionally, State Bs protocols address using an alternative IV site as deemed necessary by the medical
team, or alternative execution by intramuscular injection, both upon direction from the warden after
consultation with the director.
State C
Within 10 days of receiving the warrant of execution, the inmate chooses penalty of death by either
lethal gas or lethal injection.
Preparation: Approximately three hours prior to a scheduled execution, the execution team
administrator and the team leader remove the lethal injection chemicals and saline from the lethal
injection facility safe and transfer custody to two members of the infusion sub-team. One member of
the infusion sub-team prepares the lethal injection chemicals and saline syringes on the first color-coded
tray. The tray has identical, matching syringes labeled by content and sequence of administration. The
other infusion sub-team member verifies proper preparation of the syringes. A record keeper observes
and documents the process. Another infusion sub-team member prepares the lethal injection chemicals
and saline syringes on the second color-coded tray. The tray has identical, matching syringes labeled by
content and sequence of administration. A different infusion sub-team member verifies proper
preparation of the syringes. A record keeper observes and documents the process.
Administration: The inmate is escorted into the execution room. The IV sub-team member places the
electronic monitoring sensors on the inmate, inserts two catheters into pre-designated veins, and
reports to the infusion control room to continuously monitor the saline drips. One member of the IV
sub-team remains in the execution room to continuously monitor the IV lines. This IV sub-team member
stands next to the inmate and assesses the consciousness of the inmate throughout the execution. The
warden physically remains in the execution room in close proximity to the inmate. Upon direction from
the warden, the infusion sub-team administers the lethal injection chemicals and saline. A record
keeping sub-team member initiates a 10-minute countdown at the start of the infusion. Following
administration of the first IV drug, the inmates consciousness level is reviewed. Observations are
documented, and if the inmate is unconscious, the lethal injection procedure continues. If after 10
minutes the inmate has not died, the warden directs the additional syringes of execution drugs be
intravenously administered in accordance with policy. Upon completion of the process, death is
pronounced.
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December 15, 2014
Additionally, State Cs protocols address using an alternative IV site as deemed necessary by the IV subteam upon direction from the warden.
State D
Seven days prior to the scheduled execution, State Ds warden determines whether a sufficient amount
of the one-drug protocol is available for use, or whether the two-drug protocol will be utilized. The
commissioner notifies the inmate of the drug protocol identified.
Preparation: The IV team, 24 hours prior to the execution, completes an examination of the inmates
veins to determine possible locations of the IV sites. On the day of the execution, the warden provides
the IV team with sufficient amounts of the lethal injection chemicals to prepare two syringes for the
drug protocol identified. At the execution building, one member of the IV team prepares the syringes.
A second member of the IV team observes the process and verifies the procedures were carried out
correctly. A member of the IV team determines the appropriate size needle based on the examination
of the inmates veins.
Administration: The inmate is escorted into the execution room. The IV team runs two IV lines: one
primary and one backup. If the IV team cannot secure two sites within one hour, the execution is
scheduled for a later date. The execution team connects the electrodes of the cardiac monitor to the
inmate and ensures the equipment is functioning. During the execution, the warden and deputy warden
watch the primary IV site for any problems. Upon direction from the warden, the lethal injection
protocol is administered. If the inmate is not unconscious within 60 seconds, the warden stops the
process in the primary site and orders the backup be used with a new flow of chemicals. Once the lethal
injection is complete, a designated execution team member starts a stopwatch. If after 10 minutes the
coroner is not able to declare death, the injections continue until death has occurred. Upon completion
of the process, death is declared.
State E
Upon receipt of the warrant of execution, a designated execution team member purchases and, at all
times, ensures a sufficient supply of the chemicals to be used in the lethal injection process.
Preparation: On the day of the execution, an execution team member, in the presence of one or more
additional team members and independent law enforcement observer, prepares the lethal injection
chemicals, ensuring that the syringes are appropriately labeled and include the name of the chemical
contained within. The execution team member who prepared the two lethal chemical stands transports
them personally, in the presence of one or more additional members of the execution team, to the
executioners room and places them in the appropriate locations. The lethal injection chemicals remain
secure until the executioner arrives. A designated execution team member also prepares two standard
IV infusion sets of pre-filled sterile plastic bags of normal saline for IV use.
Administration: A designated member of the execution team escorts the two executioners into the
executioners room. The inmate is escorted into the execution chamber. Two heart monitor leads are
attached to the inmates chest. An execution team member establishes two IV lines and tests the
viability of the IV site with a saline drip. Witnesses are escorted into the witness room, and the
20

December 15, 2014
execution chamber and executioners room are secured. Upon direction from the warden, in the
presence of the secondary executioner, one or more execution team members, and an independent law
enforcement monitor, the primary executioner administers the lethal chemicals in accordance with
policy. Following administration of the IV drugs, the inmates consciousness level is reviewed. If the
inmate is unconscious, the process continues as initiated. If the inmate is not unconscious, the warden
suspends the execution process, establishes a secondary access site, or designates an execution team
member to secure a peripheral venous or central venous line placement and continues the execution
utilizing the second stand of lethal chemicals. Upon completion of the process, death is pronounced.
State F
The director has sole discretion 30 calendar days prior to the scheduled execution date as to which
chemicals will be used for the execution using a one-, two- or three-drug protocol. State Fs director
provides the drug protocol identified to the inmate no less than 10 calendar days prior to the scheduled
execution date.
Preparation: At the appropriate time, the housing unit section chief transfers custody of the chemical(s)
from a secure location to the special operations team to begin the chemical(s) and syringe preparation
in the chemical room under the direct supervision by the IV team leader. The team prepares one
complete set of chemicals, labeling the assigned syringes in a distinctive manner and identifying the
specific chemical(s) contained in each syringe by assigned number, chemical name, chemical amount,
and designated color in conformance with chemical chart protocols. The flow of each gauge is checked
by the IV team leader; the syringes are affixed to the manifold in the proper order and verified by the
operations team leader.
Administration: The inmate is escorted into the execution room and positioned on the table to enable
the IV team or the special operations team leader and the housing unit section chief to directly observe
the offender and to monitor the offender with the aid of a high-resolution color camera and a highresolution color monitor. A microphone is affixed to the inmate to allow the team in the chemical room
to hear any utterances or noises made by the inmate throughout the procedure. Throughout the
procedure, the IV team leader monitors the offenders level of consciousness. After one hour of
unsuccessful IV attempts, the director contacts the governor or designee to potentially request a
postponement of the execution. A flow of heparin/saline is started in each line and administered at a
slow rate to keep the lines open. The housing unit section chief remains in the room with the inmate
throughout the administration of the chemicals in a position sufficient to clearly observe the inmate and
the primary and backup IV sites for any potential problems and immediately notifies the IV team leader
and director should any issue occur. At the appropriate time, the director orders the administration of
chemical(s) to begin. The assigned special operations team member visually and orally confirms the
chemical name on the syringe and then administers the full dose of the chemicals immediately followed
by the heparin/saline flush. After five minutes has elapsed, the IV team leader enters the room to
confirm the inmate is unconscious by using all necessary and medically-approved methods. If after five
minutes the offender remains conscious, the director may instruct the special operations team to
administer an additional dose of the lethal chemical(s) followed by the heparin/saline flush. The IV team
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December 15, 2014
leader again physically confirms the offender is unconscious. When all electrical activity of the heart has
ceased, the IV team leader confirms the inmate is deceased, and the inmates death is announced by the
director. The special operations team recorder documents on the special operations team log the start
and end times of the administration of the lethal chemical(s). The IV team members, special operations
team members, and the housing unit section chief continually monitor the inmate using all available
means to ensure the inmate remains unconscious and that there are no complications.
State G
Prior to the scheduled execution, designated staff are responsible for ensuring all chemicals used in the
lethal injection execution in State G are available and properly stored.
Preparation: A member of the drug team prepares one syringe of normal saline and one syringe of the
lethal injection chemical(s). The drug team also prepares a back-up set in case unforeseen events make
their use necessary.
Administration: The inmate is escorted into the execution chamber. A medically trained individual
inserts two IV catheters: one primary and one backup. There is no time limit to properly insert the IV
lines. A normal saline solution at a slow rate commences. The director and warden or their designees,
as well as a medically trained individual, observe the IV line to ensure the rate of flow is uninterrupted.
The director or his designee gives the order to commence with the execution. The warden or designee
instructs the drug team to induce, by syringe, substances necessary to cause death. The flow of normal
saline through the IV line is discontinued. The lethal dose of chemical(s) commences. The lines are
flushed with normal saline. The director or designee and warden or designee observe the appearance of
the inmate during the application of the lethal chemicals. If visible signs of life are exhibited after a
sufficient time for death has passed, the director or designee instructs the drug team to administer
additional chemicals, followed by a saline flush. After a sufficient time has passed, the warden directs
the physician to enter the execution chamber and examines the inmate, pronounces death, and
designates the official time of death.
State H
Prior to the scheduled execution, all controlled chemicals, a disposition log, and lockable transport case
are kept in the pharmacy.
Preparation: On the day of the scheduled execution, an authorized team member draws keys and
proceeds to the pharmacy to obtain the appropriate amount of chemicals. Within two hours of the
scheduled execution, the chemicals are delivered to the chemical room. The IV team performs a check
of all necessary equipment and instruments. Within one hour of the scheduled execution, the chemicals
are drawn into syringes to be used by the injection team by a trained staff member and supervised by a
nurse. Two sets of syringes are prepared at the dosage identified in the procedure, and the remaining
chemicals and syringes are locked in the transport case and stored nearby in the event they are needed.
Administration: The inmate is escorted into the execution room. The IV team runs two IV lines. If the IV
team cannot secure access, a physician provides access by central venous cannulation or other medically
approved alternative. A nurse from the IV team applies the heart monitor leads. Upon the order from
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December 15, 2014
the warden, the execution process commences. A staff member monitors the time when the injection
process begins. The first member of the injection team injects one syringe, the second member of the
injection team injects an additional syringe, and a third member of the injection team injects saline,
ensuring a steady, even flow of chemical. A nurse monitors the progress to ensure proper delivery of
the chemicals and to monitor for any signs of consciousness. If after a sufficient time for death to have
occurred the inmate exhibits visible signs of life, the warden instructs the injection team to administer
additional chemicals. Upon completion of the injection of the final syringe, the designated physician
advises the warden when the heart monitor indicates that the inmate is deceased. If the inmate shows
residual signs of life within a reasonable period after all injections have been completed, the injection
sequence is repeated upon the order of the warden. Upon completion of the process, death is declared.
State I
Preparation: Medical personnel prepare the lethal chemicals. The quantities of these chemicals may
not be changed without prior approval of the director. The chemicals are prepared and labeled as
syringes 1 and 2, with the chemical name and amount of solution; and syringe 3, with 30 cc of saline
solution. Additional chemicals are prepared and labeled as syringes 4 and 5, with the chemical name and
amount of solution; and syringe 6, with 30 ccs of saline solution. Syringe 6 is prepared in the event that
additional flush is required.
Administration: Medical personnel determine the most appropriate location for the IV lines. Both a
primary and secondary IV line are inserted unless the prisoners physical condition makes it unduly
difficult to insert more than one IV. Properly trained medical personnel may insert the primary IV line as
a peripheral line or as a central venous line. The secondary line is a peripheral line. A sufficient quantity
of saline solution is injected to confirm the IV lines have been properly inserted and that the lines are
not obstructed. The gurney is positioned so that medical personnel can observe the prisoners face
directly or with the aid of a mirror. Medical personnel monitor the prisoner during the execution. Upon
order of the director, the chemicals are injected into the prisoner by the execution team members
under the observation of medical personnel. The lights in the execution support room are maintained at
a sufficient level to permit proper administration of the chemicals. Syringes 1 and 2 are injected. The
saline solution from syringe 3 is injected. Following a sufficient amount of time for death to occur after
the injection of syringe 3, medical personnel examine the inmate to determine if death has occurred. If
the inmate is still breathing, syringes 4 and 5 are injected, followed by syringe 6. At the completion of
the process, and after a sufficient time for death to have occurred, medical personnel evaluate the
prisoner to confirm death. In the event that the appropriate medical personnel cannot confirm that
death has occurred, the curtain is reopened until an appropriate amount of time has passed to
reevaluate the inmate.
State J
This jurisdiction identified the preferred three-drug protocol with the following chemicals: 500 mg
midazolam hydrochloride, 600 mg rocuronium bromide, and 240 mEq potassium chloride. There were
no additional preparation or administration protocols provided by State J.
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December 15, 2014
OBSERVATIONS AND CONCLUSIONS FROM PROTOCOL REVIEW

The comparative review of the ADOC protocols to the requirements of the other state systems reviewed
found that in all areas the ADOC execution procedures as outlined in Department Order 710 and
observed by the project team equaled or surpassed the provisions contained in the protocol standards
reviewed from the other jurisdictions. In particular, the specificity of the procedures, the
comprehensive nature of its provisions, and the training regime that was documented for all team
members could serve as national standards for other systems.
24

December 15, 2014
OBSERVATIONS OF THE ADOC PROTOCOL

ADOC Department Order 710, Execution Procedures, enumerates detailed procedures required for each
staff member participating in the execution process and sets forth the timeframes within which each
procedure is to occur. Ten execution procedure checklists have been prepared for all required
protocols. The checklists are assigned to the general counsel, the office of victim services, the inspector
general, the deputy director for offender operations, the director, the ASPC-Eyman warden, the division
director for health services, the media and public relations office, the ASPC-Florence warden, and the
southern region operations director to ensure all procedures are followed as required by Arizonas
execution procedures. The execution timeline is initiated upon receipt of the warrant of execution and
is established in increments of 35 days, 21 days, 14 days, 2 days, 24 hours, and 12 hours prior to
execution and post-execution procedures.
A comparative review of the execution procedures checklists utilized in the July 23, 2014, execution of
inmate Wood and the Arizona execution procedures verified that all checklist requirements were
completed appropriately. Review details are summarized in the following. Each item was
independently confirmed as completed through the review of checklists, documents, and interviews
completed with staff participants.
Warrant Receipt: May 28, 2014
Upon receipt of the warrant of execution from the attorney generals office, the general counsel made
all required notifications for inmate Joseph R. Wood III.
35 Days Prior to Execution: June 18, 2014
The office of victim services identified and advised the victims of the crime of the scheduled
execution.
The deputy director for offender operations identified execution team leaders and members,
established and activated the training schedule, confirmed preventive maintenance of
equipment, planned and coordinated all operational activities between staff and locations, and
initiated the continuous observation log.
The director approved the execution team members and IV team members and team leader.
The ASPC-Eyman warden read the warrant of execution to the inmate, outlined how conditions
of confinement would be modified, offered the inmate to speak to an attorney or a chaplain,
obtained the inmates current weight, transferred the inmate to a single-person cell, placed the
inmate on 24-hour continuous observation, established an observation record, implemented all
required conditions of confinement, completed all witness and notification information,
directed the inmate to update his Notification of Inmate Hospitalization or Death and
Property, and advised the inmate he could request a last meal.
The assistant director for health services directed the health services staff to conduct a medical
records file review, dispense all inmate medications in unit doses and eliminate keep-on-person
medications, initiate continuous monitoring of the inmates medical or mental health for
25

December 15, 2014
significant changes, and identified trained medical personnel to be on standby in the event the
inmate experienced a medical emergency prior to the execution.
The media and public relations office issued a news advisory announcing the date of the
execution and facilitated non-contact interviews with the inmate by phone.
21 Days Prior to Execution: July 1, 2014
The inspector general conducted licensing and criminal history reviews of the IV team members
and conducted background investigations for media witnesses.
The director invited the attorney general, 12 reputable citizens, media witnesses, crime victims
and survivors, and the inmate witnesses to witness the scheduled execution. The director
provided notice to the Arizona Supreme Court and parties of the scheduled time of the
execution (20 days prior) and provided the inmate with written notice of the selected chemical
protocol to be utilized in the execution.
The media and public relations office forwarded witness applications to the inspector general
for background investigation and sent witness agreement forms to the identified witnesses.
The general counsel finalized a list of official, victim, and inmate witnesses, including pool
reporters for the directors approval.
The office of victim services finalized the list of victims interested in witnessing the execution for
the directors approval.
The inspector general finalized arrangements with the medical examiner for disposition of the
body, vehicle security, and custodial transfer of the body and obtained a body bag and tag from
the medical examiners office.
The ASPC-Eyman warden confirmed receipt of the inmate witness and notification information
form, confirmed the review of the notification in case of accident, serious illness or death and
disposition of property form, confirmed the review of any changes to the disposition of remains
form, and confirmed receipt of the last meal request form.
The media and public relations office issued a news advisory announcing the date and time of
the execution and finalized media official witness/pool reporter functions.
The deputy director for offender operations conducted two training sessions with multiple
scenarios and confirmed adequate staffing and vehicles in place for regular operations and the
scheduled execution.
The ASPC-Florence warden confirmed staff assigned to the maintenance response team would
be on site eight hours prior to the execution time, restricted access to the housing unit, readied
the housing unit for inmate transfer, and verified the execution inventory and equipment checks
were completed and open issues resolved.
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December 15, 2014
24 Hours Prior to Execution: July 22, 2014
The ASPC-Eyman warden ensured the inmate received his last meal timely, ensured non-contact
visits and phone calls were concluded timely, and ensured the inmate was prepared for transfer
timely.
The assistant director for health services confirmed trained medical personnel were scheduled
to be at a pre-designated area four hours prior to the execution and confirmed medical
equipment was present and operational.
12 Hours Prior to and Through Execution: July 23, 2014
The ASPC-Eyman warden restricted access to institution property.

The ASPC-Florence warden restricted access to institution property.
The deputy director for offender operations directed the transfer of the inmate to Housing Unit
9, ensured staff took custody of the inmate and the maintenance of the observation log, offered
the inmate a mild sedative, offered the inmate a light meal, ensured the inmate remained on
continuous watch, issued the appropriate clothing, ensured the cell was furnished appropriately,
and provided the inmate with pencil, paper, religious items, and hygiene supplies for the
duration of use.
The director provided a brief overview of the execution to the witnesses in the staging areas,
conferred with the attorney general and the governors office general counsel to confirm no
legal impediment to proceed with the lawful execution, determined the use of IV method after
receiving advice from the IV team leader, after inmate was secured on execution table
reconfirmed with the attorney general and the governors office general counsel that there was
no legal impediment to proceeding, instructed the disbursement of chemicals to begin by the
prescribed means, announced death, made proper notifications of death, and filed the death
warrant within 48 hours after death.
The south region operations director coordinated the monitoring and evaluation of the inmate
activity at ASPC-Eyman and ASPC-Florence, assessing the inmate population for any activity
related to the execution or its impact on the prisons operations.
The media and public relations office provided the news media with regular briefings, provided
general information about the execution and inmate, provided the media representatives
information on how the press pool would be established, provided a summary of the inmates
final 24 hours of activity, and provided each pool reporter with a tablet of paper and pencil to
take notes.
Post Execution:
The inspector general had the CIU investigator take photos of the inmates body while
restrained, prior to placement in body bag, without restraints, prior to placement in body bag,
sealed in body bag, and photo of seal in place on body bag.
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December 15, 2014
IDENTIFIED CHECKLIST DISCREPANCIES

The review of the checklists did identify minor discrepancies in compliance to the requirements
contained in the protocols, including the following:
General counsel checklist - includes references that were not applicable. Specifically,
forwarding the original warrant of execution to the warden of ASPC-Florence (710.01-1.1.1.2),
sending a copy of the original warrant of execution to the warden of ASPC-Eyman (710.011.1.1.3), and preparing for the director written notification to the sentencing court and the
supreme court stating the time, mode, and manner in which the warrant was carried out
(710.13-1.4.2).
Deputy director for offender operations checklist - does not make reference to offering the
inmate a mild sedative no later than four hours prior to the execution (710.12 1.2.5).
Assistant director for health services checklist - references 35 days prior responsibilities as
Section 710.06, et seq. However, the proper reference in the execution procedures is 710.07, et
seq.
None of these discrepancies impacted the execution of Joseph R. Wood III.
EXECUTION LOGS DAY OF EXECUTION

To further document the details of the execution, the ADOC Execution Procedures identifies team
members to serve as recorders. The execution team recorders completed three correctional service logs
during the execution of inmate Wood. Specifically, logs were completed for the Housing Unit 9 section
leader, the lethal injection room, and Housing Unit 9 special operations. A consolidated log identifying
the events documented on the day of the Wood execution follows:
Time
Event
0800
Special Operations and IV Teams assembled for execution of inmate:

Wood, Joseph ADC #086279.
0800
Execution table is prepared at least two hours prior to scheduled time of

execution.
0804
Audio, visual and medical equipment inspected. Witness Room AV feed off.
0818
IV Team Leader checked and verified the flow of each gauge and confirmed
there are no obstructions in the manifold or lines.
0819
Commenced the preparation of chemicals and syringes.
0835
Completed preparing, labeling and affixing syringes to the manifold.
0836
Special Operations Team Leader verified that all syringes are properly
labeled and affixed to the correct location on the manifold.
0916
All items are removed from inmates cell (Linen, property, etc.).
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December 15, 2014
0918
Housing Unit 9 Section leader advises Director that inmate is ready for
search and restraint; requests permission to proceed. Director grants
permission to proceed.
0921
Director receives call from Donna Hallam (Arizona Supreme Court) advising
a temporary stay will be issued.
0922
Director advises the Housing Unit 9 Section leader to disregard the search
and restraint of the inmate.
0950
Director receives call from Arizona Supreme Court advising a temporary

stay has been issued.
1003
Director exits Housing Unit 9 to brief witnesses regarding the temporary

stay.
1113
Director advises stay has been lifted.
1313
Inmate placed in upper restraints by restraint/escort team after strip

search.
1313
Restraint Team Leader notifies Housing Unit 9 Section Leader that inmate is
restrained and the team is ready to move the inmate to the injection room.
1319
Housing Unit 9 Section leader advises Director all witnesses have arrived at
internal staging and requests permission to apply lower restraints to the
inmate and move to the injection room.
1320
Director makes initial call to the Governors General Counsel to ascertain if

there are any reasons to not proceed with the execution. Per Governors
General Counsel, at this time there is no reason to not proceed.
1321
Director makes initial call to the Attorney Generals Office to ascertain if

there are any reasons to not proceed with the execution. At this time there
is no reason to not proceed.
1321
The Director informs Housing Unit 9 Section Leader (proceed with

movement of inmate to the injection room).
1321
Housing Unit 9 Section Leader advises Command to begin movement of

witnesses to Housing Unit 9 witness room.
1322
Inmate escorted to Execution Room; one staff in front, two at the inmates
sides, Restrain Team Leader behind. Support Staff behind Restraint Team
Leader.
1323
Restraint team enters lethal injection room.
1323
Legs restrained. (maintain good circulation).
1323
Harness applied.
1324
Remove left (hard) restraint.
29

December 15, 2014
1324
Apply left (soft) restraint.
1324
RTL asks inmate if it feels ok; inmate nods.
1325
Left arm restrained.
1325
Remove right (hard) restraint.
1325
RTL advises inmate they are to apply pulse monitor.
1325
Apply right (soft) restraint.
1325
Right arm restrained.
1325
RTL asks inmate if it feels ok; inmate nods.
1325
Remove belly chains.
1326
RTL advises inmate they are going to have to shave his upper body.
1328
EKG leads, Pulse/Oxygen monitor, and blood pressure cuff attached. Initial
blood pressure: 137/84.
1329
RTL advises inmate they are going to apply a second blood pressure cuff.
1329
Restraint Team Leader checks all restraints.
1329
RTL asks inmate if left restraint feels alright.
1330
Inmate advises RTL that its a little tight but it wont matter in a few
minutes. Also states youll see a scar under there.
1330
RLT advises inmate they will adjust it.
1330
Inmate says thank you.
1330
Inmate is restrained.
1331
Restraint Team Leader advises the Housing Unit 9 Section leader that
inmate is restrained to the table.
1331
Command advised Housing Unit 9 Section Leader that all witnesses are in
place. Housing Unit 9 Section Leader advises Director witnesses are in
place.
1331
RTL advises inmate our IV team is going to come in and do an assessment.
1333
RTL ask inmate if he feels ok; inmate advises yes but its a little cold in here.
1334
Housing Unit 9 Section Leader advises the Director the inmate is secure on
the table and ready for the IV procedure. Director grants permission to
proceed.
1335
Monitor is turned on in the witness room.
1335
IV Team enters lethal injection room, and conducts vein assessment.
1335
IVTL advises inmate they are here to do the IV procedure; and right now
30

December 15, 2014
they are just going to do an assessment.

1336
IVTL advises the inmate theyll be right back.
1337
Acting upon the advice of the IV Team Leader, the Director determines the
catheter site(s).
1338
IV Team explains IV procedure to the inmate.
1338
IVTL advises the inmate they are going to apply a tourniquet.
1340
IV procedure commenced.
1340
IVTL advises the inmate he will get this done as quick as he can. Also
advises the inmate hes going to feel a little stick.
1340
IVTL advises the inmate he is going to remove the tourniquet and blood
pressure cuff.
1341
RTM asks SO for primary line.
1341
RTM asks SO to check flow.
1341
SO advises RTM flow is good.
1342
IVTM advises the inmate they are going to do the same on this side.
1344
RTM asks SO for secondary line.
1345
RTM asks SO to check flow.
1346
SO advises RTM flow is good.
1346
Restraint/Escort Team Leader and Housing Unit 9 Section Leader positioned

in Execution Room. Special Ops Team Leader inside the Chemical Room.
Inmate is secured to the table with the IV flowing, EKG functioning.
1347
IV procedure completed. Primary IV catheter placed in inmates left A/C.

Backup IV catheter placed in inmates right A/C.
1347
Housing Unit 9 Section Leader advises Director that IV procedure is

complete.
1347
IV Team exits the lethal injection room.
1347
RTL advises the inmate that over to his right when the curtains open the
witnesses will be there.
1348
Director makes call to the Governors General Counsel to ascertain if there

are any reasons to not proceed with the execution. Per Governors General
Counsel, at this time there is no reason to not proceed.
1349
Director makes call to the Attorney Generals Office to ascertain if there are
any reasons to not proceed with the execution. Per Attorney Generals
Office, at this time there is no reason to not proceed.
31

December 15, 2014
1349
The Director informs Housing Unit 9 Section Leader we may proceed.
1349
Restraint Team exits the lethal injection room.
1349
With permission from the Director and confirmation to proceed, Housing

Unit 9 Section leader opens the curtains.
1350
Housing Unit 9 Section Leader reads the Execution Order.
1351
Housing Unit 9 Section Leader asks inmate if he would like to make a last
statement.
1351
Inmate makes his last statement.
1352
Director instructed Special Ops Team Leader to commence with drug

protocol:
1352
Syringe 1A
1353.22
Syringe 2A
1353
Syringe 3A
1354
Drug protocol completed.
1356
3 minute point: 1356.22. Confirmed 3 minutes have elapsed since

commencing the administration of chemicals.
1357
IV Team Leader verified the inmate is sedated.
1357
Housing Unit 9 Section Leader advises witnesses the inmate has been
sedated.
1408
Syringe 1B
1409
Syringe 2B
1409
Syringe 3B
1410
Second Drug Protocol Complete.
1413
2C Bank A
1416
3C Bank A
1416
Third Drug Protocol Complete.
1423
Director orders IV Team to assess sedation and check IV.
1424
Inmate remains sedated.
1424
Inmate remains sedated. No issues with IV.
1425
1D Bank A
1426
2D Bank A
1427
3D Bank A
32

December 15, 2014
1427
4th Drug Protocol Complete.
1433
1E Bank B
1434
2E Bank B
1434
3E Bank B
1434
1441
1442
1442
1443
1F Bank A
1444
2F Bank A
1444
3F Bank A
1445
1449
1450
1450
1452
2G Bank B
1452
3G Bank B
1453
1458
1459
2H Bank A
3H Bank A
th
1459
8 Drug Protocol Complete.
1501
1502
1502
1502
2I Bank B
1504
3I Bank B
1504
1507
2J Bank A
1509
3J Bank A
1509

33

December 15, 2014
1515
Director makes call to Governors Office to give update on execution and

assessment of inmate.
1529
1530
1530
1531
2K Bank B
1531
3K Bank B
1532
1532
2L Bank A
1533
3L Bank A
1533
1536
1537
2M Bank B
3M Bank B
th
1537
1539
1540
1540
1540
1541
2N Bank A
3N Bank A
th
1541
1542
Director speaks to Jeff Zick in the Attorney Generals Office regarding

contingency plan and proceeding with execution.
1545
2O Bank B
1545
3O Bank B
1546
1548
1549
IV Team Leader pronounced death.
1549
Director informed of death by Special Ops Team Leader.
1549
Director advises witnesses that the execution is concluded.
1549
Housing Unit 9 Section Leader closes the curtains.
1550
Housing Unit 9 Section Leader notifies command to proceed with removal

34

December 15, 2014
of witnesses from Delta Staging.

1553
CIU Investigator examines the body.
1553
Coroner/Medical Examiner examines the body.
1602
Housing Unit 9 Section Leader instructs IV Team to cut lines to IVs.
1607
Team enters and removes restraints from the inmate and places inmate on
a gurney.
1608
Restraint/Escort Team assists Coroner in the removal of the inmates body.
1609
All Teams perform clean up duties.
1620
Housing Unit 9 Section Leader gives directives to secure the Execution

Facility.
End Log.
35

December 15, 2014
TRAINING
The ADOC execution procedures require the director to schedule, on a continuous rolling basis, 10
training scenarios within a 12-month period. This ensures that 10 training scenarios will precede any
scheduled execution. In addition, the procedures require a minimum of two training sessions with
multiple scenarios 2 days prior to the scheduled execution. All training sessions are documented, and
beginning 35 days prior to the scheduled execution date, execution team members who are
participating in the execution receive training, written instruction, and practiceall of which is
documented.
A review of documented training and training scenarios for the execution team members included:
Records of execution team members years of experience on the execution team

Training records for the period of October 2010 through July 2014
Execution training notes identifying training provided to team members for the period of
October 2013 through July 2014
The project teams review of these records found that the Arizona execution team followed all required
procedures as set forth in Arizonas Department Order 710, Execution Procedures.
EXECUTION TEAM MEMBERS YEARS OF EXPERIENCE ON EXECUTION TEAM

The ADOCs 15-member execution team had a combined total of 65 years of experience serving as
execution team members at the time they participated in the July 23, 2014, execution of Mr. Wood.
Three of the members each had 7 years of experience, one member had 6 years of experience, four
members each had 5 years of experience, one member had 4 years of experience, two members each
had 3 years of experience, three members each had 2 years of experience, and one member had 1
year of experience. In summary, this team was experienced and well-trained.
TRAINING RECORDS REVIEWED FOR THE PERIOD OF OCTOBER 2010 THROUGH JULY 2014
The ADOC provided training records for the execution team members for the period of October 2010
through July 2014. During that timeframe, the ADOC provided a total of 54 training sessions, which
included a total of 253 simulations/scenarios.
For the time period preceding the July 23, 2014, execution of Mr. Wood, specifically October 2013
through July 2014, ADOCs execution team exceeded the training requirements outlined in their
execution procedures. Although the execution team is required to conduct 10 training scenarios within
12 months preceding a scheduled execution and 2 training sessions with multiple scenarios two days
prior a scheduled execution, the Wood execution team participated in a total of 44
simulations/scenarios within a nine-month period preceding the July 23, 2014 execution and
participated in 2 training sessions with 13 simulations/scenarios two days prior to the execution.
36

December 15, 2014
Review details are as follows:

Wood Execution Date: July 23, 2014
Training Dates
Number of Simulations/Scenarios
July 22, 2014
July 21, 2014
July 08, 2014
October 22, 2013
October 21, 2013
October 08, 2013
October 07, 2013
Total Training Sessions
44
EXECUTION TRAINING NOTES IDENTIFYING TRAINING PROVIDED TO TEAM MEMBERS

In addition to the multiple training scenarios conducted during the nine months preceding the Wood
execution, the ADOC execution team members complied with the protocol requirement to train on
multiple scenarios for the two days immediately preceding the Wood execution. This review confirmed
the training details for the two days prior to the execution:
Wood Execution Date: July 23, 2014
Training completed on July 22, 2014
Briefing: Training records document that the director discussed current status of court action.
The execution team practiced seven simulation scenarios, including the monitor/microphone procedure
in the witness room and all simulation scenarios involving the IV team leader and IV team member with
internal teams.
Simulation #1: Two-drug protocol. Full scenario included all procedures from cell to table. Normal IV
procedures. No issues with IV. No issues with inmates behavior. Practiced procedures with
monitor/microphone in witness room. Right peripheral line used (primary) and left peripheral line
(back-up).
Simulation #2: Two-drug protocol. Full scenario from table. Normal IV procedures. No issues with IV.
No issues with inmates behavior. Practiced procedures with monitor/microphone in witness room.
Right femoral line used (primary) and right peripheral (back-up).
Simulation #3: Two-drug protocol. Full scenario from table. Syringe failure in 2A. New syringe loaded
with two-drug protocol (82 seconds commenced to back-up). No issues with inmates behavior.
Practiced procedure with monitor/microphone in witness room. Right peripheral line used (primary)
and left peripheral (back-up).
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December 15, 2014
Simulation #4: Two-drug protocol. Full scenario from table. Cross-train leaders. Normal IV procedures,
(inmate complains during IV procedure). Practiced procedures with monitor/microphone in witness
room. Right peripheral line used (primary) and left peripheral (back-up).
Simulation #5: Two-drug protocol. Full scenario from cell to table. Normal IV procedure. No issues with
IV. No issues with inmates behavior. Practiced procedure with monitor/microphone in witness room.
Right peripheral line used (primary) and left peripheral (back-up).
Simulation #6: Two-drug protocol. Full scenario from table. Syringe failure in 1A. Commenced to backup set (1 minute, 42 seconds commenced to back-up). No issues with inmates behavior. Practiced
procedure with monitor/microphone in witness room. Right peripheral line used (primary) and left
peripheral (back-up).
Simulation #7: Two-drug protocol. Full scenario from table. Normal IV procedures. No issues with IV.
No issues with inmates behavior. Practiced procedure with monitor/microphone in witness room.
Right femoral line used (primary) and right peripheral (back-up).
Training Completed on July 21, 2014
Briefing: Operations Division Director discussed current status of court action.
Team practiced six simulation scenarios including monitor/microphone procedure in the witness room
and all simulation scenarios involving internal teams.
Simulation #1: Two-drug protocol. Full scenario from cell to table. Normal IV procedures. No issues
with IV. No issues with inmates behavior. Practiced procedures with monitor/microphone in witness
room. Right femoral line used (primary) and left peripheral line (back-up).
Simulation #2: Two-drug protocol. Full scenario from cell to table. Syringe failure in 2A. New syringe
loaded (90 seconds commenced to back-up). No issues with inmates behavior. Practiced procedures
with monitor/microphone in witness room. Right peripheral line used (primary) and right peripheral
(calf, as back-up).
Simulation #3: Two-drug protocol. Full scenario from table. Cross-train section leaders. Normal IV
procedures. No issues with IV. No issues with inmates behavior. Practiced procedure with
monitor/microphone in witness room. Left femoral line used (primary) and right peripheral (back-up).
Simulation #4: Two-drug protocol. Full scenario from table. Cross-train section backups. (Inmate
refuses to be restrained, warden talks to inmate). Normal IV procedures. No issues with IV. Practiced
procedures with monitor/microphone in witness room. Right femoral line used (primary) and left
peripheral (back-up).
Simulation #5: Two-drug protocol. Full scenario from cell to table. Normal IV procedure. No issues with
IV. No issues with inmates behavior. Practiced procedure with monitor/microphone in witness room.
Right peripheral line used (primary) and left peripheral (back-up).
38

December 15, 2014
Simulation #6: Two-drug protocol. Full scenario from cell to table. (Difficulty inserting IV). No issues
with inmates behavior. Practiced procedure with monitor/microphone in witness room. Right femoral
line used (primary) and left peripheral (back-up).
39

December 15, 2014
SUMMARY OF STATE DRUG PROTOCOLS

As noted previously, the project team completed a comparative review of lethal injection protocols for
the ADOC and the 10 state protocols that were obtained through discussion with the administrative
officials of the various state systems. The drug protocols of two additional states were obtained verbally
but the information provided was limited to the chemical components used in the execution protocol
for those specific states. As a result, information was obtained from 12 systems on the various elements
of the drug protocols. The project team was able to review the protocols and interview staff where
necessary to clarify any provisions contained in the protocols. The state systems in which the protocols
were provided and are considered public documents included Arizona, Ohio, Kentucky, Oklahoma,
Texas, and Missouri. Four other states provided information on their protocols or permitted the project
team to review the documents, but did not provide a copy of the protocol. Two other states provided
detailed information only on the chemicals used in the execution protocol. The information noted below
was obtained through a review of the protocols that were provided and through discussion with staff
involved in the process with additional information available through court documents, news reports,
and statements for those involved in the process in each state.
Most of the jurisdictions reviewed have multiple options for the drug compounds utilized. This is
necessary due to the need to have flexibility to respond to the fluctuations in the availability of the
specific drugs required for the execution. In the past, most systems relied on a one-drug protocol
consisting of thiopental, propofol, and pentobarbital. Pentobarbital had proven to be effective and
reliable. However, the availability of pentobarbital has been greatly reduced and most systems no
longer have access to the chemical. Selected systems, such as Texas and Missouri, have either stocked
the drug or have found sources to obtain the necessary amounts. Others have developed alternative
protocols consisting of a variety of chemicals.
The protocols reviewed utilized the following protocols:
Arizona
One-drug protocol with pentobarbital
Syringe 1A
60 ml heparin/saline
Syringe 2A
2.5 gm pentobarbital
Syringe 3A
Syringe 4A
One-drug protocol with sodium pentothal
Syringe 1A
Syringe 2A
1.25 gm sodium pentothal
Syringe 3A
Syringe 4A
Syringe 5A
Syringe 6A
Two-drug protocol with midazolam and hydromorphone
Syringe 1A
Syringe 2A
50 mg midazolam and 50 mg hydromorphone
40

December 15, 2014
Syringe 3A
State B
Syringes 1 and 2
5 gm pentobarbital (divided into two syringes, labeled 1 and 2)
Syringes 3 and 4
5 gm pentobarbital (divided into two syringes, labeled 3 and 4)
Two-drug protocol with midazolam and hydromophone
Syringe 1
50 mg midazolam, 50 mg hydromorphone
Syringe 2
Syringe 3
60 mg hydromorphone
Note: Additional syringes of 60 mg hydromorphone shall also be obtained or prepared if needed.
Two-drug protocol with midazolam and hydromorphone with intermuscular injection
Syringe A
Syringe B
Syringe C
60 mg hydromorphone
Note: Additional syringes of 60 mg hydromorphone shall also be obtained or prepared if needed.
State C
Three-drug protocol with sodium thiopental, pancuronium bromide and potassium chloride
Tray A:
1. 60 cc Syringe
1.5 grams sodium thiopental
2. 60 cc Syringe
1.5 grams sodium thiopental
3. 60 cc Syringe
50 cc saline flush
4. 60 cc Syringe
50 mg pancuronium bromide
5. 60 cc Syringe
50 cc saline flush
6. 60 cc Syringe
100 milliequivalents potassium chloride
7. 60 cc Syringe
8. 60 cc Syringe
50 cc saline flush
Note: Tray B is prepared identically to Tray A and used as a back-up.
State D
One-drug protocol with sodium thiopental or pentobarbital
Inject 3 gm of sodium thiopental or 5 gm of pentobarbital
Note: If it appears to the warden, based on his visual inspection, that the inmate is not
unconscious within 60 seconds of his command to proceed, the warden shall stop the flow of the
sodium thiopental or pentobarbital in the primary site and order that the backup IV be used.
Inject 10 mg midazolam and 40 mg hydromorphone
Note: If it appears to the warden, based on his visual inspection, that the inmate is not
unconscious within 60 seconds of his command to proceed, the warden shall stop the flow of the
midazolam and hydromorphone in the primary site and order that the backup IV be used.
41

December 15, 2014
State E
Three-drug protocol with midazolam hydrochloride, vecuronium bromide and potassium chloride
Tray A:
Syringe 1A
250 mg midazolam hydrocloride
250 mg midazolam hydrochloride 20 ml
Syringe 2A
sterile solution
Syringe 3A
50 mg vecuronium bromide
Syringe 4A
Syringe 5A
20 ml sterile solution
Syringe 6A
Syringe 7A
Syringe 8A
Tray B:
Syringe 1A
250 mg midazolam hydrocloride 250 mg
Syringe 2A
midazolam hydrochloride 20 ml sterile
Syringe 3A
solution
Syringe 4A
Syringe 5A
Syringe 6A
20 ml sterile solution
Syringe 7A
Syringe 8A
State F
Syringe 1A
Syringe 2A
Syringe 3A
Syringe 1A
Syringe 2A
Syringe 3A
Syringe 4A
Syringe 5A
Syringe 1A
250 mg midazolam
Syringe 2A
250 mg midazolam
Syringe 3A
Syringe 4A
500 mg hydromorphone
Syringe 5A
Three-drug protocol with midazolam, vecuronium bromide and potassium chloride
Syringe 1A
250 mg midazolam
Syringe 2A
250 mg midazolam
Syringe 3A
Syringe 4A
Syringe 5A
Syringe 6A
Syringe 7A
42

December 15, 2014
Syringe 8A
Syringe 9A

State G
One (1) syringe of normal saline shall be prepared
100 ml of solution containing 5 grams of pentobarbital
Note: The drug team shall have available a back-up set of normal saline syringe and lethal
injection drug in case of unforeseen events.
State H
Syringe 1
2.5 grams pentobarbital
Syringe 2
2.5 grams pentobarbital
Syringe 3
60 cc saline solution
Note: A secondary set of syringes numbered 1, 2, and 3 will be prepared in a manner outlined
above if additional dosage of pentobarbital is needed.
State I
Syringe 1
5 grams pentobarbital
Syringe 2
Syringe 3
Syringe 4
Syringe 5
Syringe 6
State J
Three-drug protocol with midazolam hydrochloride, rocuronium bromide and potassium chloride
500 mg midazolam hydrochloride
600 mg rocuronium bromide
State K
Three-drug protocol with brevital, vecuronium bromide and potassium chloride
50 mg brevital
State L
Three-drug protocol with midazolam hydrochloride, rocuronium bromide and potassium chloride
500 mg midazolam hydrochloride
600 mg rocuronium bromide
43

December 15, 2014
DRUG PROTOCOL CONSIDERATIONS AND REVIEW

In the execution of Joseph R. Wood III, the ADOC utilized the following two-drug protocol.
Syringe 1A
Syringe 2A
Syringe 3A
50 mg midazolam and 50 mg hydromorphone
The drug protocol was initiated at 1:52 p.m. At 1:57 p.m., the IV team leader indicated that Wood was
sedated. At 2:08 p.m., the second set of the drug protocol was administered. The process continued
until the drug protocol was administered for the fifteenth time at 3:46 p.m. At 3:49 p.m., the IV team
leader pronounced death.
In comparison, Ohio conducted an execution on January 16, 2014, using the same drug combination as
was used in the Wood executionbut in lesser amounts than used in the Wood executionwith the
death of the inmate in 26 minutes. The amounts used in the Ohio execution were as follows:
Syringe A
Syringe B
Syringe C
60 mg hydromorphone
Information reviewed on the prior executions conducted by the ADOC confirmed that the Wood
execution time lapse was significantly longer than any prior event. The following summarizes the
executions that occurred since April 2012 and includes the drug protocol utilized and the time lapse
from initiating the execution to time of death.
Date of Execution
4/25/2012
6/27/2012
8/8/2012
12/5/2012
10/9/2013
10/23/2013
7/23/2014
Drug Protocol
Pentobarbital
Pentobarbital
Pentobarbital
Pentobarbital
Pentobarbital
Pentobarbital
Midazolam,
Hydromorphone
Elapsed Time
7 minutes
29 minutes
37 minutes
20 minutes
9 minutes
17 minutes
114 minutes
A review of the prior versions of ADOC Policy 710 indicated that the processes and procedures utilized in
the above-noted executions were similar. The obvious difference in the Wood execution and the prior
executions noted above is the drug combination used during the execution. The Wood execution
utilized the two-drug combination of midazolam and hydromorphone for the first time in Arizona.
IV TEAM LEADER
The IV team leader is an experienced physician with critical care and trauma specialties. He was assisted
by a second IV team member who is an experienced trauma paramedic. During an interview with the IV
team leader he outlined his major responsibilities during the execution protocol. They included drawing
44

December 15, 2014
the correct amounts of the chemicals and mixing the chemicals in accordance to the drug protocol. He
confirmed that in the Wood execution he drew and mixed the chemicals and confirmed that the correct
amount was to be utilized. He also noted that there were no problems encountered with starting the
IVs and that the flow through the IVs was uninhibited.
Upon starting the flow of chemicals, the IV team leader reported that he monitored the level of
sedation. In the case of Woods, he reported that the inmate became sedated very quickly. Throughout
the course of the protocol Wood remained heavily sedated. He felt that the breathing that was observed
by the witnesses was reflexive and not an indication that Wood was not totally sedated. During the
course of the protocol he conducted tests on Wood to determine the level of sedation and
responsiveness. He indicated he was totally unresponsive to stimuli. He reported that he conducted
standard tests to confirm sedation including using a cotton swab on the cornea of the eye and a pin
prick to determine if there was any reflexive response. He reported in the course of these tests there
was no response from Wood.
He was asked if there were chemicals that could serve as blockers to negate or reduce the effect of the
chemicals used in this case. He did indicate that there were potential blockers, but they would only
serve to slow the process. He also indicated that the amount of saline injected would not in any way
dilute or lessen the effect of the midazolam and hydromorphone. He stated that the saline was used to
prevent clotting and to keep the IV line open and flowing.
The IV team leader reported that the chemicals in this case sedate and suppress respiration, and the
dosage given initially should normally have been sufficient to cause death in a short period of time. He
added that everyone reacts differently to chemical agents and drugs, and in this case the midazolam was
effective, but for an unknown reason did not cause death until additional dosages were given over the
time period specified.
He indicated that in his opinion Wood was not suffering during this process and was sedated fully at all
times.
MEDICAL EXAMINER
The autopsy report was prepared and issued by Gregory Hess, MD, Medical Examiner of Pima County,
Arizona. The Medical Examiner of Pima County completes autopsies for deaths occurring in Pinal
County, Arizona, consistent with a contractual agreement between the two counties. ASPC-Florence is
located in Pinal County.
The final autopsy report, which is dated August 22, 2014, states that the ..cause of death is ascribed
to mixed drug intoxication due to judicial execution by lethal injection. 1 Dr. Hess was interviewed by
the project team relative to the results of the autopsy and his opinions and observations that stem from
this autopsy.
The observations of Dr. Hess as stated to the project team are as follows:
1
Autopsy Report, Joseph Rudolph Wood III, Pinal County, Arizona, Case #2014-020218.
45

December 15, 2014
There was nothing unusual about this particular case in comparison with other autopsies he has
completed on execution cases of the ADOC.
He observed that the catheters/IV had been properly placed and did not appear obstructed.
The toxicology report confirmed the presence of high levels of midazolam and hydromorphone.
Dr. Hess provided no explanation of why the drugs did not result in death in a short time period.
He noted that everyones physical makeup results in a variety of responses to the introduction
of drugs.
He noted that the ADOC does not monitor brain activity, and it is possible that brain death
occurred much sooner than the actual pronouncement of death.
He noted that gasps, snorting, and body reflexes are the normal bodily responses to dying, even
in someone highly sedated.
It is clear that the execution of Wood and the resulting time delays cannot be correlated to the issues
that occurred with the execution on April 29, 2014 of Clayton Lockett in Oklahoma. In the case of
Lockett, the Oklahoma Department of Corrections has acknowledged that the catheters and IV had not
been properly placed thus restricting the flow of the drugs. Nothing similar to that occurred in the
Wood execution. The process and the implementation of the protocol was not botched as has been
described in the Lockett execution.
INDEPENDENT MEDICAL EXPERT

The project team also reviewed the Wood execution and the range of available drug options with a
physician who is an independent correctional health expert and is familiar with the issues involved in the
administration of drugs during lethal injections. This physician is a board-certified Diplomate of the
American Board of Internal Medicine and Diplomate of the American Board of Quality Assurance and
Utilization Review Physicians.
The drug protocol used by the ADOC was outlined to him, and he could not offer an explanation as to
why the initial administration of drugs was not sufficient to complete the execution. He stated that the
amount administered far exceeded what is the normal clinical dosage (1 to 2 mg of midazolam and 1 mg
of hydromorphone). Given the dosage administered to Wood, he would expect the elapsed time to be
less than that experienced in Ohio in the McGuire execution. He also opined that the amount of the
initial dosage to Wood would result in heavy sedation.
He was familiar with the Ohio case involving the execution of Dennis McGuire on January 16, 2014, and
the discussion about the use of the two-drug protocol involving midazolam and hydromorphone. As he
stated, Ohio faced the same situation that many states have faced recently due to the lack of availability
of the preferred drug, pentobarbital. He concurred with the decision of the Arizona Department of
Corrections to increase the midazolam and hydromorphone dosages in the aftermath of the McGuire
execution.
In reviewing the options that other states are utilizing given the lack of availability of pentobarbital, he
concurred that the three-drug option of midazolam, rocuronium or vecuronium bromide, and potassium
46

December 15, 2014
chloride would be appropriate. He added, however, that large doses of hydromorphone, which causes
apnea (cessation of breathing), combined with high doses of midazolam, which results in sedation,
should be an effective option.
47

December 15, 2014
FINDINGS AND RECOMMENDATIONS

1. The review of the ADOC Execution Protocols indicates that the provisions of the policy are
detailed, specific in terms of responsibilities, comprehensive in scope, and provide guidance and
direction for all elements of the execution process.
2. A comparison to other protocols and policies within other state systems indicates that the ADOC
Execution Protocols meets or exceeds the standards established by other states in terms of
scope of coverage of responsibilities and specificity of tasks and assigned duties.
3. Interviews with key participants of the Wood execution indicate that the staffs working
knowledge of the provisions of the protocols, individual duties and responsibilities, and
contingencies if required was excellent. Staff was found to be knowledgeable, experienced, and
well-trained.
4. A review of training records indicates that staff assigned to execution teams are well-trained
and proficient in the requirements of the protocols and all contingency plans in the event that
an unexpected event occurs during the execution.
5. A review of the implementation of the execution protocols in the Wood case found no
breakdowns in the implementation of the process or the mechanical systems supporting the
execution. Staff performed all required functions consistent with the requirements of the
protocol. Staff performance in no way contributed to the extended time lapse from initiation of
the drug protocol to pronouncement of death. As noted the execution was not botched in
comparison to what occurred in Oklahoma with Clayton Lockett.
6. There was no contingency or practiced scenario for the events that occurred with the Wood
execution. The review of other state protocols found no contingency action in any of the
reviewed protocols for the event that occurred with the Wood execution. The ADOC should
review the event with the IV team leader and toxicologists and develop contingencies if a similar
delay occurs in the future.
7. Discussion with other state administrators and leadership indicate that many states are facing
the same challenge as Arizona in terms of access to the preferred chemicals. Only two states
claimed access to pentobarbital at this time. All others have developed options, some identical
to the two-drug protocol used in the Wood execution. Others have moved to a three-drug
protocol consisting of 500 mg midazolam hydrochloride, 600 mg rocuronium or 100 mg
vecuronium bromide, and 240 milliequivalents potassium chloride.
8. The medical examiner in this case offered no apparent explanation for the time lapse that
occurred in the Wood execution. The IV team leader, medical examiner, and an independent
correctional health expert agreed that the dosage administered was sufficient to cause death in
a relatively short period of time. All agreed that the dosage of midazolam would result in heavy
sedation.
9. The Arizona two-drug protocol was consistent with the protocol used in the execution of Dennis
McGuire in Ohio and was, in fact, an increased amount compared to the drugs used in that
particular execution. The testimony of the medical experts in the Ohio case was consistent with
48

December 15, 2014
the opinions of the IV team leader and the medical examiner in terms of anticipated effect. It is
noted that the time lapse in the Ohio case was less than the time lapse in two executions in
Arizona that utilized the preferred drug, pentobarbital (6/27/2012, 29 minutes and 8/8/12, 37
minutes). This is an indication of the validity of the statements of medical personnel that the
manner that each individual system responds and reacts to the introduction of drugs into their
system fluctuates and is sometimes unpredictable.
10. Both the IV team leader and the medical examiner indicated that the catheter and the IV
delivery system were in the correct position and that the drugs were administered to Wood
consistent with the protocol.
11. It is recommended that the ADOC retain the one-drug option currently included in the protocol.
These are as follows:
Syringe 1A
60 ml. heparin/saline
Syringe 2A
Syringe 3A
Syringe 4A
60 ml. heparin/saline
Syringe 1A
Syringe 2A
Syringe 3A
Syringe 4A
Syringe 5A
Syringe 6A
Each of these options provides a record of being effective and efficient in multiple jurisdictions
over a long period of time and should be available as an option if the drugs become available to
the ADOC in the future.
12. It is recommended that the ADOC replace the existing two-drug option with a drug protocol
consisting of the following:
a. 500 mg midazolam hydrochloride
b. 600 mg rocuronium or 100 mg vecuronium bromide
c. 240 milliequivalents potassium chloride
13. The above protocol has been adopted by at least four other systems in the past year and is
considered reliable and effective by these systems. Florida successfully utilized this drug
protocol for eight executions in 2014 as of the submission of this report 2. If access to these
drugs becomes problematic, the ADOC should consider using the same mixture as utilized in the
2
Death Penalty Information Center; Execution List 2014. (www.deathpenaltyinfo.org.)
49

December 15, 2014
Wood case but at higher dosages250 midazolam and 250 mg of hydromorphone. Other state
systems have adopted this enhanced dosage as a contingency in the event that preferred drugs
are not accessible.
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ARIZONA DEPARTMENT OF CORRECTIONS

Consulting Services for Assessment and

Assessment and Review of the

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

SUMMARY OF KEY TASKS

Arizona Department of Corrections Execution Protocols

Charles Ryan, Director, Arizona Department of Corrections

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

HOUSING UNIT 9 REVIEW

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

Selection process of execution team members

COMPOSITION OF EXECUTION TEAM AND SELECTION PROCESS

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

EXECUTION TEAM MEMBER TRAINING

Arizona Department of Corrections Execution Protocols

EXECUTION TEAM RECORD KEEPING

Medical assessment of prisoner

Arizona Department of Corrections Execution Protocols

Execution team training

Arizona Department of Corrections Execution Protocols

Equipment accountability report

Execution drug storage

Team member approval

Arizona Department of Corrections Execution Protocols

Special operations team recorder execution timeline

Execution summary packet

Controlled chemical inventory

Disposal of unused chemicals

MEDICAL FILE REVIEW

Arizona Department of Corrections Execution Protocols

EXECUTION TEAM PREPARATION AND ADMINISTRATION OF DRUG PROTOCOL

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

Arizona Department of Corrections Execution Protocols

OBSERVATIONS AND CONCLUSIONS FROM PROTOCOL REVIEW

Arizona Department of Corrections Execution Protocols

OBSERVATIONS OF THE ADOC PROTOCOL

Arizona Department of Corrections Execution Protocols

21 Days Prior to Execution: July 1, 2014

14 Days Prior to Execution: July 9, 2014

2 Days Prior to Execution: July 21, 2014

Arizona Department of Corrections Execution Protocols

24 Hours Prior to Execution: July 22, 2014

12 Hours Prior to and Through Execution: July 23, 2014

The ASPC-Eyman warden restricted access to institution property.

Arizona Department of Corrections Execution Protocols

IDENTIFIED CHECKLIST DISCREPANCIES

None of these discrepancies impacted the execution of Joseph R. Wood III.

EXECUTION LOGS DAY OF EXECUTION

Special Operations and IV Teams assembled for execution of inmate:

Execution table is prepared at least two hours prior to scheduled time of